DECLARATION OF INTENTION TO PRESENT A DEBTOR S PETITION SUSPENSION OF CREDITOR ENFORCEMENT Bankruptcy Act 1966 Section 54A

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1 DECLARATION OF INTENTION TO PRESENT A DEBTOR S PETITION SUSPENSION OF CREDITOR ENFORCEMENT Bankruptcy Act 1966 Section 54A Privacy The information you are required to provide on this form is collected under, and for the purposes of, the Bankruptcy Act 1966 or related legislation. The Australian Financial Security Authority has a privacy policy at that provides information regarding the collection, storage, use and disclosure of personal information, including how you may: (i) access your personal information; (ii) seek to have that information corrected; and (iii) complain if you feel your privacy has been breached, along with information on how your complaint will be dealt with. Relevant Information For a period of 21 days beginning on the day this application is accepted, your creditors, the bailiff or sheriff will be restrained from taking action to recover your unsecured debts - such as seizing your assets or garnisheeing your wages. But secured creditors may still repossess any assets over which they hold security (such as a car under finance). This will give you time to consider all your options and discuss alternative arrangements with your creditors. If you have not made arrangements with your creditors by the end of the 21 day period, you do not have to voluntarily proceed to bankruptcy but a creditor can use the fact that you have lodged this form to apply to the Court to make you bankrupt. If, having considered all your options, you determine that bankruptcy is your best option, you may lodge a Debtor's Petition with the Official Receiver at any time during or after the 21 day period. AFSA may give the information you provide on this form to any trustee administering your estate should you become bankrupt. Contact Details Other names used by you in the past 10 years Home number Fax number Work number Mobile number address Address Postcode Current occupation Date of birth (DD/MM/YYYY) page 1 of 6

2 Authority to Act If you would like to authorise a person (financial counsellor, accountant, solicitor etc) to talk with creditors on your behalf, the authorised person should sign the statement below. Business address Postcode Work number Fax number address What is the relationship of the authorised person to the debtor? Financial counsellor Registered trustee Solicitor Accountant Debt agreement administrator Other (please describe) Declaration of the Authorised Person I agree to act on behalf of the above named debtor and understand that my contact details will be provided to the creditors listed herein to facilitate negotiations on the debtor's behalf. Signature of authorised person Your Financial Affairs Total annual income (before tax) ($) Number of dependants (the number of people who live with you and are dependent on you for economic support) Income source (tick and provide details where applicable) Wages/ salary Employer name Government benefits/ pensions Business/ self employed Type of benefits Name of business/ company Any other source Please specify page 2 of 6

3 Secured Assets (assets over which a creditor holds security eg a house property with a mortgage) The listed creditors will be notified of acceptance of this application. It is important that you list all of your creditors. Please copy this page if you have more than 4 secured creditors Description of asset (eg 2005 Commodore) Name, postal address and reference number of the secured creditor (eg ABC Finance 123 Finance St. Sydney NSW 2000 Ref. No: ) Estimated value in $ (eg $10,000) Amount owing in $ (eg $7,000) Is this creditor related to you? Is there any joint owner of the asset? Vehicle Real estate Other Other Other Assets (tick and provide details wherever applicable) Type of asset Estimated value in $ Is there any joint owner of the asset? Cash Funds in bank accounts Money owed to you Shares Investments Vehicle Business assets Other (please list below) page 3 of 6

4 Unsecured Creditors (for example credit cards, unpaid bills, loans from friends and relatives) List all creditors that have not already been listed under "Secured Assets" section. The listed creditors will be notified of acceptance of this application. It is important that you list all of your creditors. Please copy this page if you have more than 10 unsecured creditors. You must disclose if a creditor is related to you. Tax debts: If you owe a debt to the Australian Taxation Office, when listing this debt below please do not enter your Tax File Number (TFN) Creditor type (eg credit card) Creditor's name and address Reference number Amount owing in $ Is this creditor related to you? Is this a joint debt? Confirmation to Sheriff or Paymaster If you want confirmation of the acceptance of this application faxed or ed to either the Sheriff or Paymaster please provide their contact details below. First person Contact name Organisation Address address or fax number Reference number page 4 of 6

5 Second person Contact name Organisation Address Address or fax number Reference number Declaration of the Debtor Pursuant to s54a I declare that, to my knowledge, the information contained in this form is true and correct. I also consent to the person authorised on page 2 of this form to talk with creditors on my behalf. A person must not make a declaration that the person knows to be false: Penalty imprisonment for 12 months s267. Signature of debtor Declaration of person who assisted with completion of form (to be completed if assistance provided to debtor to complete form) I declare that before this form was completed, I carefully read to/interpreted for the person named above the prescribed information and the questions on this form or [where the person is physically incapacitated] satisfied myself that the person had read and understood the information and questions. The responses provided in this form are those of the person named above. Signature of the person assisting Full Name and address of the assisting person Reason the debtor required your assistance Accepted by the Official Receiver when endorsed below Office Use Only page 5 of 6

6 PRESCRIBED INFORMATION You must read the following information before signing the declaration. Your Options to Deal with Unmanageable Debt Talk to your creditors: some creditors could give you more time to pay, agree to renegotiate repayments or accept a smaller payment to settle the debt. Some creditors have hardship provisions which you can use to vary the terms of your contract. You should call your creditors and ask about their hardship provisions. Lodge a declaration of intention to present a debtor s petition: this stops your creditors, the bailiff or sheriff taking action to recover unsecured debts for a period of 21 days. You could use that time to speak to your creditors, consider other options or seek advice. Propose and enter a debt agreement (DA): a debt agreement is a legally binding arrangement between you and your creditors which must be accepted by the majority of your creditors. The agreement is administered by a debt agreement administrator who will charge a fee. Your debts, assets and income must be under certain limits* to propose a DA. You can offer to pay your creditors by instalments or in a lump sum which may be less than the full amount of your debts. You will be released from debts covered by the agreement once you have completed all obligations and payments in your agreement. Your name will be on the public register (NPII) forever and on a commercial credit record for 5 years, or longer in some circumstances. See the paragraph Your ability to obtain credit and certain services may be affected at the bottom of this page for additional information and obligations. Propose and enter a personal insolvency agreement (PIA): a PIA is also a legally binding arrangement between you and your creditors which must be accepted by a majority of your creditors. The PIA must be administered by a trustee who will charge a fee. There are no debt, asset or income limits. You can offer to pay your creditors by instalments or in a lump sum which may be less than the full amount of your debts. You will be released from debts covered by the agreement once you have completed all obligations and payments in your agreement. Your name will be on the public register (NPII) forever and on a commercial credit record for 5 years, or longer in some circumstances. Sources of further information: you can ask for help from a financial counselling service, registered trustee, registered debt agreement administrator, lawyer or an accountant. They will talk to you about your options and may speak to creditors on your behalf. You can get more information about the above options or sources of financial guidance by contacting AFSA on or by visiting Consequences of Proceeding with a Petition for Bankruptcy A trustee will administer your bankruptcy: you may ask a registered trustee to administer your bankruptcy. If you do not choose a trustee, AFSA may ask a registered trustee to become your trustee, otherwise the Official Trustee (AFSA) will become your trustee. Your creditors can change your trustee. You must assist your trustee at all times. You must immediately notify your trustee in writing of any change in your personal circumstances (including name, address or income). Your trustee can extend the 3 year period of bankruptcy to 5 or 8 years under certain circumstances. Usually a trustee will take a fee for administering your bankruptcy out of the assets or income they recover. Your assets may be sold: you will be able to keep ordinary household goods, tools (up to a certain value)* used to earn an income and vehicles (up to a certain value)* but other assets - including your house - can be sold by your trustee. You cannot conceal, remove or dispose of any property inside or outside Australia. If you do, you may be subject to criminal prosecution. Your income, employment and business may be affected: if your income exceeds a set limit*, you may be required to make contributions from your income. You cannot be a director of and/or manage a company. Some professional/licensing bodies may restrict or prevent you from continuing in that trade or profession. You may not be able to hold certain public positions. If you are in business and trade under a business name different to your own, you must tell everyone you deal with that you are bankrupt. If you don t, you may be subject to criminal prosecution. You may not be released from all debts: you are released from most of your unsecured debts (eg credit cards, personal loans, store cards) once you are discharged from bankruptcy. Some types of debts are not covered by bankruptcy (eg debts incurred by fraud, penalties/fines and child support debts) and you have to continue paying those debts. If a debt is secured against an asset (eg mortgage on a house or a car) and you do not maintain repayments, that creditor can repossess and sell the asset; however the shortfall, if any, will be covered by bankruptcy. Your ability to travel overseas will be affected: you will not be able to travel overseas without the written permission of your trustee and you may be asked to surrender your passport to your trustee. If your bankruptcy is administered by the Official Trustee, you will be required to pay an overseas travel application fee. Your name will be on the public register (NPII) forever: it will also be recorded on a commercial credit record for 5 years, or longer in some circumstances. Your ability to obtain credit and certain services may be affected: you may find it hard to borrow money and buy things on credit. You may find it hard to rent and get electricity, water or a telephone connected without paying a bond. Some banks may not let you operate an account or may restrict how you can use your account. If you obtain credit of $3,000 or more* then you must tell the credit provider that you are bankrupt. If you enter into a hire purchase agreement or a contract for the hiring or leasing of any goods whereby the amount is or totals $3,000 or more* then you must tell the seller or the property owner that you are bankrupt. If you obtain goods and services by giving a bill of exchange, cheque or promissory note whereby the amount is or totals $3,000 or more* then you must tell the supplier of the goods or services that you are bankrupt. If you obtain goods and services by promising to pay an amount of $3,000 or more* then you must tell the supplier of the goods or services that you are bankrupt. If you obtain money or payment of $3,000 or more* by promising to supply goods or render services, you must tell the purchaser that you are bankrupt. If you don t disclose your bankruptcy in these circumstances, you may be liable to criminal prosecution. *This is an indexable amount and therefore increases periodically (see s304a of the Bankruptcy Act). For the current limits and monetary amounts see Indexed Amounts at or call AFSA on for a copy. I Acknowledge that I have Received and Read the Prescribed Information Your signature page 6 of 6